Priority Health Medicare
The choice is easy.
NCMS_6000_6014_A 05092013
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Great reasons to choose us
• 25+ years of health care experience in Michigan
• Priority Health is a nationally recognized health
benefits company. We consistently rank among the
nation's top health plans for quality and service
• #1 Medicare plan in the state
• 19,000+ providers– including the University of
Michigan Health System
• 57,000 pharmacies nationwide. 98% of pharmacies
in the U.S. are in our national network
Priority Health is health plan with a Medicare contract.
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Employer-sponsored options:
High
Mid
Low
• Employer sponsors coverage for Medicare-eligibles via an MAPD
plan – technically known as Employer Group Waiver Plan (EGWP)
• Employer contributes money/stipend and Medicare-eligibles choose
desired individual coverage (MAPD or Medigap plan)
•Employer involvement low – simply wants to assist Medicareeligibles with transition into individual coverage
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Why choose a Priority Health Medicare
plan?
• Control rising health care costs with our
growing portfolio of high quality, affordable
Medicare plans.
• Offer competitive benefits to both retired
employees and those looking forward to
retirement.
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Three great reasons to choose
Priority Health Medicare
#1 Improve your bottom line
• Save 10 – 15% by moving people 65 and older away from your
group plan without sacrificing the quality of their benefits.
• Drug plan administration handled by Priority Health now that
Affordable Care Act removed your Retiree Drug Subsidy
(RDS).
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Three great reasons to choose
Priority Health Medicare
#2 Enhance your benefits
Retain the best employees by adding an employersponsored Priority Health Medicare plan to your overall
benefits package.
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Three great reasons to choose
Priority Health Medicare
#3 Plans for employers of all sizes
• Choose from two standard Medicare Advantage plans
with enhanced hospitalization benefits, prescription drug
coverage in the “donut hole” and worldwide coverage for
urgent and emergency care.
• No minimum employer contribution necessary for
companies of 20 or more employees.
• We can create custom plans for (companies with 100 or
more employees).
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Our members love us!
• More individuals choose Priority Health Medicare
Advantage plans over any other plan in Michigan*
• Our individual PriorityMedicare ValueSM (HMO-POS)
and PriorityMedicareSM (HMO-POS) plans were
awarded 4.5 stars (out of 5) by the Centers for Medicare
and Medicaid Services**
• Our plans received the highest accreditation status of
"Excellent" from the National Committee for Quality
Assurance (NCQA).
*According to January 2012 - April 2013 monthly enrollment reports from the Centers for Medicare
and Medicaid Services.
**Plan performance star ratings are assessed each year and may change from one year to the next.
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Our group Medicare Advantage plans
• Offer additional benefits beyond what you get with Original
Medicare
• Include prescription drug coverage with no “donut hole” and a
home delivery option
• Coverage in the United States and around the world
• Have predictable out-of-pocket expenses
• Include doctor visits and hospital coverage
• Don’t require a referral to see a specialist
• Local, exceptional customer service
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Standard plan benefits
Benefits in-network
PriorityMedicare (HMO-POS) Basic
PriorityMedicare (HMO-POS) Enhanced
Annual deductible
$250
$0
Doctor/specialist
office visit
$15/$30 copayment
$10/$25 copayment
$0 copayment
$0 copayment
Emergency/urgent
care
$65/$45 copayment
$65/$40 copayment
Diagnostic tests and
lab services
$0/$150 copayment
$0/$100 copayment
Inpatient medical
hospital care
Preventive care
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$0 copayment for all preventive services covered by Original Medicare
$0 copayment for an annual physical exam
Standard plan benefits
Benefits in-network
Part D prescription
drug coverage (31day retail copay/
coinsurance)
PriorityMedicare (HMO-POS) (basic)
$15 for generics
$50 for preferred brand
$80 for non-preferred brand
20% specialty up to $150 maximum
PriorityMedicare (HMO-POS) (enhanced)
$10 for generics
$40 for preferred brand
$70 for non-preferred brand
20% specialty up to $100 maximum
Includes coverage through the coverage gap
Hearing
$0 copayment for routine hearing tests,
including Medicare-covered diagnostic
hearing exams.
An office visit copayment may apply.
$300 allowance for hearing aids every
three years
$0 copayment for routine hearing tests,
including Medicare-covered diagnostic
hearing exams.
An office visit copayment may apply.
$200 allowance for hearing aids every three
years
Vision
$30 copayment for Medicare-covered
exams to diagnose and treat diseases and
conditions of the eye.
$60 allowance for eye wear every two
years.
$25 copayment for Medicare-covered
exams to diagnose and treat diseases and
conditions of the eye.
$0 allowance for eye wear every two years.
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Medicare Advantage eligibility
• Individuals must have both Medicare Part A and
Part B to enroll
• Must be a permanent Michigan resident and reside
in our service area for at least six months of the
year. May temporarily be outside the service area
for 6 months or less
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Enrollment periods & eligibility
• Mid-year enrollment may lower your group’s
average age and positively impact your renewal
premium.
• Enrollment changes (elections) made on the group’s
renewal date thereafter.
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Get started:
Simple 4 step process
• MAPD Group Agreement
• MAPD Eligibility Verification Form
• 30-day Notification Letter
• PriorityMedicare MAPD Group Enrollment Form
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*Contact your account manager for MAPD quotes for Mid- and Large-size groups.
Employer-sponsored options:
Mid
Low
• Employer contributes money/stipend and Medicare-eligibles choose
desired individual coverage (MAPD or Medigap plan)
•Employer involvement low – simply wants to assist Medicareeligibles with transition into individual coverage
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Our Individual Medicare Advantage plans
•
PriorityMedicare ValueSM (HMO-POS)
•
PriorityMedicareSM (HMO-POS)
•
PriorityMedicare MeritSM (PPO)
•
PriorityMedicare SelectSM (PPO)
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2013 Individual Priority Health Medicare
Advantage premiums
• Premiums range from $0 to $154*
• Vary by county and plan
• Refer to the Summary of Benefits in your
individual packet for premium information
*You must continue to pay your Medicare Part B premium
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Individual MAPD benefits
Benefits
In-network
PriorityMedicare
Value (HMO-POS)
PriorityMedicare
(HMO-POS)
PriorityMedicare
Merit (PPO)
PriorityMedicare
Select (PPO)
Annual deductible
$0
$0
$325 combined in
and out of network
$0
PCP/specialist
office visit
$20/$45 copayment
$15/$40 copayment
$30/$45 copayment
$20/$40 copayment
Inpatient medical
hospital care
$800 copayment per
hospital stay
$130 copayment per
day (days 1-5)
$0 copayment per
day (days 6+)
$250 copayment per
day (days 1-5)
$0 copayment per
day (days 6+)
$125 copayment per
day (days 1-5)
$0 copayment per
day (days 6+)
Emergency/urgent
care
Lab services and
diagnostic tests
Preventive care
$65/$50 copayment
$0-$175 copayment
$0-$100 copayment
$0-$150 copayment
$0-$100 copayment
$0 copayment for all preventive services covered by Original Medicare
$0 copayment for an annual physical exam
The benefits information provided is a brief summary, not a complete description of benefits. For more
information contact Priority Health Medicare.
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Individual MAPD benefits
Benefits
In-network
PriorityMedicare
Value (HMO-POS)
PriorityMedicare
(HMO-POS)
Part D prescription
drug coverage (31day retail copay/
coinsurance)
$9 for generics
$40 for preferred
brand
$90 for nonpreferred brand
33% specialty
$8 for generics
$35 for preferred
brand
$80 for nonpreferred brand
33% specialty
Dental coverage
Includes 1 annual
preventive oral
exam and 1 annual
dental cleaning.
50% coverage for
one set of dental xrays annually. $45
copay for Medicare
covered dental
benefits.
Includes 1 annual
preventive oral
exam and 1 annual
dental cleaning.
50% coverage for
one set of dental xrays annually. $40
copay for Medicare
covered dental
benefits.
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PriorityMedicare
Merit (PPO)
PriorityMedicare
Select (PPO)
$10 for generics
$45 for preferred
brand
$90 for nonpreferred brand
33% specialty
$8 for generics
$40 for preferred
brand
$85 for nonpreferred brand
33% specialty
Not applicable
Includes 1 annual
preventive oral
exam and 1 annual
dental cleaning.
50% coverage for
one set of dental xrays annually. $40
copay for Medicare
covered dental
benefits.
Individual MAPD benefits
Benefits
In-network
Enhanced Dental
coverage for $17 a
month in addition
to your monthly
plan premium
Silver&Fit
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PriorityMedicare
Value (HMO-POS)
PriorityMedicare
(HMO-POS)
100% coverage for 2
annual preventive
oral exams and 2
annual dental
cleanings. 100%
coverage for one set
of dental x-rays
annually. 50%
coverage for
endodontic services.
50% coverage for
minor restorative
fillings.
100% coverage for 2
annual preventive
oral exams and 2
annual dental
cleanings. 100%
coverage for one set
of dental x-rays
annually. 50%
coverage for
endodontic services.
50% coverage for
minor restorative
fillings.
PriorityMedicare
Merit (PPO)
Not applicable
PriorityMedicare
Select (PPO)
100% coverage for 2
annual preventive
oral exams and 2
annual dental
cleanings. 100%
coverage for one set
of dental x-rays
annually. 50%
coverage for
endodontic services.
50% coverage for
minor restorative
fillings.
Free fitness club membership or at-home fitness kits
Why choose a Priority Health Medigap
plan?
•
Affordable - plans as low as $100 a month
•
Give you access to any Medicare provider in the U.S.
•
Generally have no copays at the time of service
•
Help pay some of the health care costs that Original Medicare doesn’t
cover
•
Have low out-of-pocket expenses
•
Automatically process and pay claims to providers
2 Preferred
rates apply for beneficiaries who are in their Open Enrollment Period or who have Guaranteed Issue
Rights, or who may qualify if they meet certain medical criteria.
Non-Standard rates apply for those not in their Open Enrollment Period or don’t have Guaranteed Issue Rights;
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also based on health status and tobacco use.
Medigap benefits
Plan A
Plan D
Plan F
Plan N
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Hospitalization
(Medicare Part A
copays plus
coverage for 365
additional days
after Medicare
benefits end)
Skilled nursing
facility care
(Part A daily
copays)
Medicare Part A
deductible:
$1,156
Medicare Part B
deductible:
$140
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Covered
Medigap benefits
Plan A
Outpatient
hospital
services
Covered
(Part B
coinsurance)
Plan D
Covered
Medicare Part B
excess charges
Hospice care
(Part A
coinsurance &
copays)
Plan F
Plan N
Covered
100% after
copay/coinsurance of
up to $20 office visit &
up to a $50 ER visit
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Blood
(First 3 pints under
Parts A & B)
Foreign travel
emergency
services4
4Lifetime
maximum of $50,000 on care received outside the U.S.
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Medigap Premium Example
Plan F: 65 year old Female, Guaranteed Issue
Kent, Ottawa
$120
Grand Traverse, Livingston, Monroe
$129
Genesee, Ingham, Macomb, Oakland,
Saginaw, Washtenaw, Wayne
$132
Kalamazoo, Muskegon, St. Clair
$136
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Eligibility requirements
•
Beneficiaries must be eligible for Medicare Part A and enrolled
in Medicare Part B
•
Must be a permanent resident of Michigan and physically
reside in the state for six months of the year
•
Can’t have more than one Medigap plan
•
Can’t have a Medigap and an MAPD plan at the same time
Neither Priority Health Medigap plans nor agents authorized to sell Priority Health Medigap plans are
connected with or endorsed by the United States government or the federal Medicare program.
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Questions?
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